Assignment 2: Digital Clinical Experience (DCE): Health History Assessment
In Week 3, you began your DCE: Health History Assessment. For this week, you will complete this Health History Assessment in your simulation tool, Shadow Health and finalize for submission.
· Review Student Checklist: Health History Guide and the History Subjective Data Checklist, provided in this week’s Learning Resources, to guide you through the necessary components of the assessment. (See attachment)
· Review the DCE (Shadow Health) Documentation Template for Health History (Attached)
· Use the template (Attached) to complete your Documentation Notes for this DCE Assignment.
Assignment Instructions :
Complete the Health History of Tina Jones (see below information and attached transcript “Tina Jones Transcript”) – To complete the assignment, please use the attached template.
Identifying Data & Reliability
Ms. Jones who is 28 yrs. old, obese African American single woman who presents to establish care and with a right foot injury.
She is the primary source of the history. Without contradiction, she freely provides specific details of her injury and of her visit. Her speech is clear and coherent. She maintains eye contact throughout the interview.
Patient is 28 yr. Old single African American, alert, awake, and oriented x 3. She is pleasant; her speech is clear and coherent. Appears healthy, well-developed and well nourished. obese.
VS obtained BP 142/82, HR 86, RR 19, T 101.1, SPO2 99%, blood sugar 235. Weighs 90kg and BMI is 31.
Ms. Jones is alert and oriented, seated upright on the examination table, and is in no apparent distress. She is well-nourished, well-developed, and dressed appropriately with good hygiene.
“I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!”
Symptoms: Right foot pain accompanied by drainage. Pain affects ability to walk or put weight on it. Also, affects sleep. Pain 7 out of 10.
Diagnosis: infected right foot wound.
History Of Present Illness
Tina fell going down the back steps of her house. Ms. Jones reports that a week ago she tripped while walking on concrete stairs outside, twisting her right ankle and scraping the ball of her foot and scraped the sole of her right foot. Her wound bled and she was able to stop the bleeding. She cleaned the wound and went to the ER fearing that she sprained her ankle. ER X-rayed her foot and reported no fracture seen. They gave her a prescription for a 5-day supply of Tramadol 50 mg. She cleaned her wound twice daily with soap and water or hydrogen peroxide, let it dry, and then she has been applying antibiotic on the scrape and covered with a dressing. The wound wasn’t getting worse, but it wasn’t getting any better. Two days ago, she noticed pus was in the wound, and that there was swelling and redness and a warm feeling in her foot. She had a fever last night and didn’t take any medication for it.
She said tramadol doesn’t seem to work too well.
She reports that ankle swelling, and pain have resolved but that the bottom of the foot is increasingly painful. The pain is described as “throbbing” and “sharp” with weight bearing. She states her ankle “ached” but is resolved. Pain is rated 7 out of 10
after a recent dose of tramadol. Pain is rated 9 with weight bearing. She reports that over the past two days the ball of the foot has become swollen and increasingly red; yesterday she noted discharge oozing from the wound. She denies any odor from the wound. Her shoes feel tight. She has been wearing slip-ons. She reports fever of 102 last night.
She denies recent illness.
Reports a 10- pound, unintentional weight loss over the month and increased appetite. Denies change in diet or level of activity.
Tylenol 500-1000 mg PO prn (DX: headaches),
Tramadaol 50 mg PO – 2 tabs PO TID (ED dispensed 30 pills) (DX: R foot pain),
Ibuprofen 600 mg PO TID (DX: menstrual cramps)
Albuterol 90 mcg/spray MDI- 2 puffs Q4H prn (DX: wheezing); last time pt used was a month ago)
Acetaminophen 500-1000 mg PO prn (headaches)
· Penicillin (rash)
· Allergic to cats and dust (sneezing, itchy eyes; asthma acts up);
denies food and latex allergies
· When she is exposed to allergens, she states that she has runny nose, itchy and swollen eyes, and increased asthma symptoms.
· Diagnosed with Type 2 diabetes at age 24, but is not taking any medication for diabetes and does not monitor blood sugar She previously took metformin, but she stopped three years ago, stating that the pills made her gassy and “it was overwhelming, taking pills and checking my sugar.” She doesn’t monitor her blood sugar. Last blood glucose was elevated last week in the emergency room.
· Asthma diagnosed at age 2 1/2. She uses her albuterol inhaler when she is around cats and dust.
She uses her inhaler 2 to 3 times per week. She was exposed to cats three days ago and had to use her inhaler once with positive relief of symptoms. She was last hospitalized for asthma “in high school”. Never intubated.
· Has irregular menstrual cycles with heavy menstrual flow and painful cramping (6 menstrual cycles/ year);
· Recent 10 pounds weight loss (not knowing how);
· Increased thirst and frequent urination.
· Sometimes has headaches.
· Vaccination is current, except for flu
· No surgeries.
· OB/GYN: Menarche, age 11. First sexual encounter at age 18, sex with men, identifies as heterosexual. Never pregnant. Last menstrual period 3 weeks ago. For the past year cycles irregular (every 4-8 weeks) with heavy bleeding lasting 9-10 days. No current partner. Used oral contraceptives in the past. When sexually active, reports she did not use condoms. Never tested for HIV/AIDS. No history of STIs or STI symptoms. Last tested for STIs four years ago.
· Hematologic: Denies bleeding, bruising, blood transfusions and history of blood clots.
· Skin: Reports acne since puberty and bumps on the back of her arms when her skin is dry. Complains of darkened skin on her neck and increase facial and body hair. She reports a few moles but no other hair or nail changes.
· Recommend to have annual check-up with OBGYN and to keep a log of menstrual cycle.
· Take blood pressure and pulse reading twice daily and keep a log of it.
· Continue to eat a daily balanced meal three times a day.
· Clean right foot wound with normal saline and cover with dry sterile dressing daily and change as needed.
· Return to clinic within a week to assess on wound and to see if an antibiotic is needed.
· Last Pap smear 4 years ago. Last eye exam in childhood.
· Last dental exam “a few years ago.”
· PPD (negative) ~2 years ago.
· No exercise.
· 24- hour Diet Recall: States that she skipped breakfast
yesterday, and would typically have a baked good for breakfast, a sandwich for lunch, and a meatloaf or chicken for dinner. Her snacks consist of pretzels or French fries.
· Immunizations: Tetanus booster was received within the past year,
influenza is not current, and human papillomavirus has not been received. She reports that she believes she is up to date on childhood vaccines and received the meningococcal vaccine in college.
· Safety: Has smoke detectors in the home, wears seatbelt in car, and does not ride a bike, Does not use sunscreen. Guns, having belonged to her dad, are in the home, locked in parent’s room.
· Father deceased in car accident one year ago at age 58, hypertension, high cholesterol, and type 2 diabetes
· Mother age 50, has high cholesterol and blood pressure, denies diabetes, occasionally drinks alcohol.
· Brother (Michael, 25): overweight
· Sister (Britney, 14): asthma but is controlled.
· Close-knit family of mother, sister, and brother.
· Both sets of grandparents have high blood pressure.
· Maternal grandmother: died at age 73 of a stroke, history of hypertension, high cholesterol
· Maternal grandfather: died at age 78 of a stroke, history of hypertension, high cholesterol
· Paternal grandmother: still living, age 82, hypertension
· Paternal grandfather: died at age 65 of colon cancer, history of type 2 diabetes
· Paternal uncle: alcoholism
· Negative for mental illness, kidney disease, sickle cell anemia, thyroid problems
· Eats a balanced diet of carbs, protein, and fat;
· She drinks 4 caffeinated drinks per day (diet coke).
· Denied nicotine and tobacco use.
· Alcohol when “out with friends, 2-3 times per month,” reports drinking no more than 3 drinks per episode.
· She has a good support system with her close-knit family of mother, sister, and brother.
· Never married, no children.
· Lived independently since age 20, currently lives with mother and sister
in a single-family home to support family after death of father one year ago.
· Employed 32 hours per week as a supervisor at Mid-American Copy and Ship. She enjoys her work and was recently promoted to shift supervisor.
· She is a part-time student, in her last semester to earn a bachelor’s degree in accounting. She hopes to advance to an accounting position within her company.
· She has a car, cell phone, and computer.
· She receives basic health insurance from work, but is deterred from healthcare due to out-of-pocket costs.
· She enjoys spending time with friends, attending Bible study, volunteering in her church, and dancing. Tina is active in her church and describes a strong family and social support system.
· She reports stressors relating to the death of her father and balancing work and school demands, and finances. She states that family and church help her cope with stress.
· Occasional cannabis uses from age 15 to age 21. Reports no use of cocaine, methamphetamines, and heroin.
· No foreign travel.
· No pets.
· Not currently in an intimate relationship, ended a three-year serious monogamous relationship two years ago.
· She plans on getting married and having children someday.